[An exceptional case of tricuspid infective endocarditis due to Bartonella henseale revealed by an old pulmonary embolism]. / Un cas exceptionnel d'endocardite infectieuse tricuspide à Bartonella henselae révélée par une embolie pulmonaire « vieillie ¼.

We report a case of blood culture-negative tricuspid infective endocarditis revealed after tick bite by repeated pulmonary infection during one year due to septic pulmonary emboli in a 67-year-old farmer woman. Tricuspid vegetation and pulmonary emboli are calcified. Lyme serology is negative. Serologic test and PCR analysis are positive to Bartonella henselae. The evolution is favorable after antibiotic and anticoagulant treatment. Infective endocarditis due to B. henselae is an exceptional complication of cat scratch disease. You have to think about in case of blood culture-negative endocarditis with calcified valvular lesions even without cat bite, tick seems to be vector of the bacteria.

[Sudden death by coronary spasm: a particular and often unrecognised clinical entity]. / Mort subite par s pasme coronaire: une entité particulière, trop souvent méconnue.

The authors report 3 cases of resuscitated sudden death in which the investigations clearly showed coronary spasm. This was demonstrated by systematic coronary angiography with an ergometric test. Two patients underwent electrophysiological investigations which were normal. The three patients were prescribed long-term calcium antagonist therapy and one of them underwent coronary angioplasty. With a follow-up of 6 months to 3 years, there was no clinical recurrence or documented arrhythmia. A review of the literature shows that this is a cause of sudden death which is probably underestimated and unrecognised. Electrophysiological investigations often give disappointing results and medical therapy is the keystone of treatment. Coronary angioplasty and implantation of an automatic defibrillator are second-line treatments reserved to forms refractory to medical therapy.

Long-term follow-up of small (size 20 and 21) Medtronic-Hall aortic valve prostheses.

BACKGROUND: Our goal was to study the long-term follow-up of patients having aortic valve replacement and to focus particularly on the patients receiving small prostheses. METHODS: Four hundred twenty-eight Medtronic-Hall valves were implanted (156 size 20 or 21 mm, 149 size 22 or 23 mm, and 123 size 25 or 27 mm). Group 20-21 had a higher number of female patients, more associated coronary lesions, and more patients with aortic stenosis. RESULTS: The actuarial survival rate at 8 years was 80% for group 20-21, 80% for group 22-23, and 76% for group 25-27 (p = not significant). In group 20-21, the actuarial event-free rates at 8 years were as follows: thromboembolic complications, 94%; prosthetic valve endocarditis, 99%; reoperation, 98%; and hemorrhagic complications, 78%. The only factors of prognostic value in this group were age and associated coronary lesions. CONCLUSIONS: The durable nature of the results obtained with the Medtronic-Hall 20- and 21-mm prostheses compared with large-diameter prostheses allows the use of a simple and reliable surgical technique and should mean that indications for ring enlargement become rare.

Thromboembolic risk and late survival after mitral valve replacement with the St. Jude Medical valve.

From January 1979 to December 1990, 397 consecutive patients (mean age, 55 +/- 11 years) underwent mitral valve replacement with the St. Jude Medical valve. Associated procedures performed were 174 multiple valve replacements, 24 coronary artery bypass graftings, 25 tricuspid repairs, and 13 left ventricular myectomies. The continuous intravenous administration of heparin was started on the first postoperative day and maintained until effective oral anticoagulation, started on the seventh day, was achieved (INR, 3 to 4.5). Follow-up consisted of 2,402 patient-years (pt-y) (mean, 6.1 +/- 0.2 years) and was 97% complete. The early (30-day) mortality was 3.5%; the 5-year and 10-year actuarial survivals were 86% +/- 4% and 73% +/- 6%, respectively. Survival was less in patients who had been in an advanced preoperative functional class (p = 0.02) and in those who underwent multiple valve replacements (p = 0.05). The 5-year and 10-year survivals in patients who underwent isolated mitral valve replacement and who were in preoperative New York Heart Association functional class II and III, were 90% +/- 5% and 82% +/- 7%, respectively. The early and late mortality and the incidence of deaths resulting from heart failure and sudden deaths were higher in patients who had undergone multiple valve replacements (p = 0.05). In terms of all deaths, 47% (36/77) were valve related (including 12 sudden deaths, 0.50%/pt-y). Thromboembolic complications occurred in 44 patients, and these were broken down as follows: embolism, 1.46%/pt-y, and valve thrombosis, 0.37%/pt-y.(ABSTRACT TRUNCATED AT 250 WORDS)

[Infectious endocarditis induced by Actinobacillus actinomycetemcomitans. 8 new cases]. / Endocardite infectieuse à Actinobacillus actinomycetemcomitans. Huit nouvelles observations.

A commensal organism of the buccal cavity, Actinobacillus actinomycetemcomitans (AAC) has been responsible for at least four new cases of infectious endocarditis by year in France. This retrospective study was based on 90 new cases of infectious endocarditis by AAC, including 8 personal observations. One third of patients had no known cardiac disease before their infectious endocarditis, the portal of entry of which was usually dental. In cases of suspected infectious endocarditis, rapid and severe weight loss (43% of cases) and, less commonly, anicteric cholestasis (8%) should alert the physician for the possible pathological role of AAC. The echocardiographic appearances are non-specific. The diagnosis is confirmed on blood cultures but the organism grows slowly in CO2 enriched atmosphere. Initially, the course of the disease was favourable in one third of patients but, in two thirds of cases, complications were observed almost renal (26%), cardiac (24%) and neurological (18%). Two thirds of patients were cured by the time they were discharged whereas the remainder had sequellae, mainly valvular and neurological. The hospital mortality was 9%; late mortality was 6%. Therefore, the prognosis of AAC endocarditis, seems to be better than that of other bacteriological forms. A combination of cephalosporin and aminoside, or even a simple third generation cephalosporin antibiotic therapy for at least 4 weeks are usually effective. The complementary surgical indications are the same as for other forms of infectious endocarditis. Prophylaxis depends on strict prophylactic amoxicillin therapy for all cardiac patients at risk of infectious endocarditis before dental treatment and on good bucco-dental hygiene.

[Surgical plasty of the coronary trunks: an alternative to bypass techniques]. / Plastie chirurgicale des troncs coronaires: une alternative aux techniques de pontages.

Between January 1991 and December 1993, surgical coronary angioplasty was performed in 12 patients with an average age of 59 years: right coronary artery (17), left main coronary artery (3) and bilateral angioplasty (2). Internal mammary or gastroepiploic artery bypass grafts were associated on another vessel in 5 patients and 1 patient also underwent aortic valve replacement. There was no early mortality (1 month), or perioperative myocardial infarction. At the 15th postoperative day, the angiographic result was satisfactory in all patients. At 6 months, exercise testing was negative in all cases (maximum load 140 +/- 20 watts). Reoperation for bypass surgery was necessary in 1 patient because of symptomatic occlusion of the left anterior descending left anterior descending artery, one year after angioplasty of the left main coronary extending to the proximal left anterior descending. With a mean postoperative follow-up of 19 +/- 7 months (6 to 31 months), all patients are asymptomatic: 5 of the 6 angioplasties controlled angiographically at 1 year were patent without any signs of progression (1 occlusion/reoperation). Surgical angioplasty of the main coronary vessels is a sure and reliable procedure: it restores physiological coronary perfusion, economises venous and arterial vessels and is no obstacle to percutaneous transluminal coronary angioplasty.

Surgical angioplasty of the coronary trunks: an alternative to bypass techniques.

AIM: To test the value of surgical angioplasty of the coronary trunks as an alternative to bypass techniques. PATIENTS AND METHODS: Surgical angioplasty of the coronary trunks was performed in 12 patients (mean age 59 +/- 9 years), of whom nine underwent right coronary trunk angioplasty, five underwent left main coronary artery angioplasty, and two patients underwent bilateral coronary trunk angioplasty. A transpulmonary approach to the left main coronary artery was used. The patch consisted of saphenous vein in the first two patients but in the rest pericardium was preferred. Associated bypass procedures to the other coronary network using internal mammary or gastroepiploic arteries were performed in six patients, and one patient had a concomitant aortic valve replacement. RESULTS: No early mortality (30-day) or morbidity was observed and all procedures were successful. A 15-day angiographic study revealed an excellent result in all 14 angioplasties. After 6 months, all patients were free of symptoms during exercise stress testing (maximum level of exercise 140 +/- 20 W). One patient with a recurrence of angina underwent a second operation after 1 year because of left anterior descending coronary artery occlusion after bilateral angioplasty. Another angiographic study was obtained after 1 year in three other patients, which showed excellent results (four angioplasties controlled). After a mean follow-up period of 17 +/- 7 months (range 6-31), all patients were symptom-free, and with the exception of the one reoperation, no cardiac events were reported. CONCLUSIONS: Provided that contraindications (calcifications, involvement of the distal bifurcation) are respected, surgical angioplasty of the coronary trunks is safe, restores physiologic coronary perfusion, is economical with bypass material, and provides good results.

[Evaluation of non invasive methods for the diagnosis of atherosclerosis of the graft after orthotopic cardiac transplantation]. / Evaluation des méthodes non invasives pour le diagnostic d'athérosclérose du greffon après transplantation cardiaque orthotopique.

The frequency and severity of atherosclerosis of the cardiac transplant make it an essential complication of cardiac transplantation. Coronary angiography is the usual diagnostic method but it has severe limitations. In order to evaluate other diagnostic methods coronary angiography and non-invasive techniques: echocardiography, exercise stress ECG, exercise radionuclide ejection fraction, stress Thallium scintigraphy, were performed practically simultaneously in 60 patients after cardiac transplantation. These non-invasive methods were said to be positive in the presence of, respectively, a segmental wall motion abnormality, ischaemic ST segment depression, absence of increased ejection fraction on exercise, reversible or irreversible myocardial hypofixation. Coronary angiography was considered as the reference procedure for distinction between "normal coronary circulation" (no angiographically detectable lesion) and "graft atherosclerosis" (at least one coronary stenosis irrespective of the severity and extension). None of the non-invasive methods had an adequate sensibility when compared with coronary angiography (echocardiography 0.27, exercise stress ECG 0.28, exercise radionuclide ejection fraction 0.64, myocardial scintigraphy 0.62) or negative predictive value (echocardiography 0.56, exercise stress ECG 0.58, exercise radionuclide ejection fraction 0.68, myocardial scintigraphy 0.66). This inadequacy of the non-invasive technique may be explained by the fact that they are more adapted to the diagnosis of myocardial ischaemia than that of coronary studies. In addition, the extent of the coronary lesions may have masked discordance between 2 segments by the global hypovascularisation. The results of this study indicate that the non-invasive methods studied cannot be recommended for diagnosis of atherosclerosis of cardiac transplants.

[Value of the positive exercise test without angina (after myocardial infarct)]. / Valeur de l'épreuve d'effort positive sans angor (après infarctus du myocarde).

In order to determine the value of a positive exercise test (ET) (i.e. ischaemic ST depression) without chest pain observed after a myocardial infarction (MI), 102 ET's were reviewed. ET was performed without anti-ischaemic drugs. The mean time-lag between MI and ET was 51 +/- 55 months. The MI was inferior in 26 cases, inferior and/or posterior in 74 cases and of undetermined location in 2 cases. Thirty patients had both ST depression and chest pain (group 1); 35 had electrocardiographic signs of ischaemia without pain (group 2), and 37 had neither chest pain nor signs of ischaemia (group 3). Age, sex ratio, site of infarction and time-lag between MI and ET were similar in all three groups. The post-ET follow-up period was 33 +/- 18 months (range: 6 to 66 months); 2 patients in group 3 were lost sight of. There was no significant difference between groups 1 and 2 as regards total duration of ET, workload attained, heart rate, systolic arterial pressure, pressure-rate product and amplitude of ST depression at maximum exercise level. Group 3 differed from the other 2 groups in workload attained (p less than 0.05) and in pressure-rate product (p less than 0.05 vs group 1, p less than 0.01 vs group 2). There was no significant difference between groups 1 and 2 as regards post-ET events (recurrent angina, reinfarction, coronary bypass, transluminal angioplasty).(ABSTRACT TRUNCATED AT 250 WORDS)

[Infective endocarditis of a valve prosthesis. Multicenter study (179 cases)]. / Endocardite infectieuse sur prothèse valvulaire. Etude multicentrique (179 cas).

Over a 5-year period (1982-1986) 176 cases of infective endocarditis on prosthesis (IEP) were recorded in 40 cardiology departments. 65 p. 100 of the patients were male, and the mean age of the population was 51 years. Mechanical prostheses were involved in 57 p. 100 of the cases and bioprosthesis in 43 p. 100. There was a high proportion of initial indications for bacterial endocarditis (18 p. 100) and for reoperation on prosthesis (10 p. 100). IEP developed early in 40 cases and late in 139 cases; 19 (48 p. 100) of the early IEPs were staphylococcal, while 31 p. 100 of late IEPs were streptococcal (p less than 0.01). 143 patients were reoperated upon within less than 1 month in 41 p. 100 of the cases, with a pre-operative antibiotic therapy of less than 10 days in 39 p. 100. Reoperation was performed in stage IV or as an emergency in 45 p. 100 of the cases. Abscesses were three times more frequent with aortic prostheses than with mitral prostheses (58 p. 100 vs 20 p. 100, p less than 0.001). Vegetations were more frequent on mechanical prostheses than on bioprostheses (43 p. 100 vs 31 p. 100, NS). The operative mortality rate was 25 p. 100; the mortality rate of unoperated patients was even higher (31 p. 100). The survival rate in operated IEP was 51 p. 100 at 30 months, as against 46 p. 100 at 12 months in unoperated IEP.(ABSTRACT TRUNCATED AT 250 WORDS)

[Recurrent infective endocarditis]. / Les endocardites infectieuses récidivantes.

Between August, 1974 and May, 1987, 486 patients were treated for infective endocarditis. In 16 of these patients (12 men, 4 women, mean age 44.3 +/- 18.0 years at the time of the first episode) the endocarditis recurred: once in 14 patients, twice in 2 patients. The time elapsed between recovery from the first episode and onset of the recurrence varied from 6 to 159 months (mean 54.3 +/- 35.1 months). Among the 18 recurrences, 10 affected native valves (mitral 6, aortic 4) and 8 aortic prostheses. In all but one case the organism isolated during the recurrence (Streptococcus in 14 cases, Staphylococcus in 3 cases, Rickettsia in 1 case) was different from the organism responsible for the previous infection. The 16 patients were followed up for periods of 28 to 203 months (mean 107.0 +/- 58.0 months), counting from the onset of the first episode. Ten patients were treated medically during the second episode: 4 died and 2 had a second recurrence, lethal in one of them (time elapsed between the onset of the first episode and the date of death: 32 to 149 months). Six patients were operated upon (valve replacement in 5 cases, closure of a left aorto-ventricular fistula in 1 case) without deaths. Nine of the 11 survivors are now asymptomatic. The actuarial survival rate in recurrent endocarditis (75 p. 100, 10 years after the onset of the first episode) is not different from that observed in non-recurrent endocarditis.

[Late results of myocardial revascularization surgery in patients with severe impairment of left ventricle dynamics. Apropos of 80 cases surgically treated from 1970 to 1979]. / Résultats tardifs de la chirurgie de revascularisation myocardique chez les patients ayant une altération majeure de la dynamique du ventricule gauche. A propos de quatre-vingt cas opérés de 1970 à 1979.

Coronary bypass surgery was performed on forty-eight patients with LVD from 1970 to 1979. Mean age was 53 +/- 9 years. All patients had abnormal motion of all walls on cineangiography and three vessel disease. Mean LVEF was 27.7%. Mean of distal anastomoses was 1.6 per patient with internal mammary artery graft to LAD. Six patients died early postoperatively (7.5%) and there were 31 late deaths. Actuarial survival including early deaths is 71.5 (+/- 6)% 5 years and 49% 10 years postoperatively. LVEF has a significant influence upon late survival (p 0.01). Because of incomplete revascularization, 55% of the 40 surviving patients, have recurrence of angina with a mean follow-up of 103 months. We have subsequently increased the mean number of bypass grafts in these patients.

[Intracoronary treatments in emergency situations]. / Traitements intracoronariens dans les situations d'urgence.

Mechanical and medicinal therapies are widely used in coronary disease patients for emergency or semi-emergency situations. Vasodilator drugs injected into arteries that are occluded or narrowed-drugs injected into arteries that are occluded or narrowed by spasm rapidly relieve that spasm; injecting these drugs prior to angioplasty renders the myocardium more tolerant to the ischaemia created by the dilated balloon. In unstable angina coronary angioplasty has a 90 p. 100 primary success rate with immediate complications that are slightly more frequent than in stable angina; compared to historical series with medicinal treatment, angioplasty reduces the risk of myocardial infarction and/or secondary death. In evolving myocardial infarcts the respective values of intracoronary thrombolysis and angioplasty are still under discussion, although the results of recent studies tend to favour intravenous thrombolysis and secondary, elective angioplasty.

Infective endocarditis on stenotic aortic valves.

Charts were reviewed of 42 adult patients (27 men, 15 women, mean age 55 years, with 17 older than 60) hospitalized and/or autopsied between 1970 and 1986 with diagnosis of definite or highly probable infective endocarditis (IE) on pure aortic stenosis (AS). Ring and/or septal abscesses were found in 18/37 patients who were operated upon and/or autopsied. IE was recognized in 32 patients, undiagnosed in 10 (revealed at autopsy in seven, at operation in three). Infecting organisms were identified in 26 patients (Str. viridans, 16; Str. D, three; Staphylo., four; other, three). Twenty-seven patients were treated in our institution, 14 of them more than four weeks after the beginning of the symptoms. Echocardiograms were recorded in 17, with vegetations in only six. Severe cardiac failure was present in 17 cases. One patient was lost to follow-up. Fourteen patients died (mean delay between IE and death 22.4 months): eight of the 13 non-operated patients (cardiac failure, four; myocardial infarction, two; neurological complications, two) and six of the 14 operated patients (peri-operative death, four; late sudden death, two). Twelve patients are alive (mean follow-up 51.6 months), eight of them in NYHA class 1. IE on pure AS is rare, difficult to recognize echocardiographically, and of poor prognosis. It usually requires rapid aortic valve replacement.

[Methods of evaluating myocardial revascularization surgery]. / Méthodes d'évaluation de la chirurgie de revascularisation myocardique.

The quality of revascularization is evaluated by measurements of blood flow and various imaging methods. The quality of the anastomosis and the graft flow are evaluated per-operatively by ultrasounds and by measurements of intramyocardial pH. After surgery, Doppler velocimetry and radioisotope scanning assess the basal coronary flow and the coronary reserve. Graft patency can be studied by noninvasive methods (Doppler and kinetic CT with contrast injection), but conventional or digital angiography is irreplaceable for visualization. Residual myocardial ischaemia and left ventricular function are evaluated by the usual methods. Angina is not sensitive enough to serve as an indicator of residual or recurrent myocardial ischaemia. ECG at rest detects most peri-operative infarctions; Holter recordings may reveal a silent myocardial ischaemia; exercise stress ECG evaluates (albeit with insufficient sensitivity) post-bypass changes in myocardial ischaemia. Myocardial scintigraphy with thallium-201 is more sensitive, and it locates low perfusion areas. Cardiac wall kinetics and left ventricular function at rest and during exercise are studied by echocardiography and contrast or isotopic ventriculography, pending advances in nuclear magnetic resonance imaging. Surgical results have never been compared with other methods of direct myocardial revascularization, but only with medical treatments. Outstanding among the controlled studies carried out are a European study (E.C.S.S.) and two North American studies (V.A.S. and C.A.S.S.); they have shown what can be expected from coronary bypass, globally and in some subgroups of patients.